Top 5 Blog Posts for 2008

My top five 2008 blog posts, based on unique page views:

1. Demand for Plumpy'Nut Outstrips Supply

2. At Work with Malawi's Nurses

3. Who Are the Health Eight (or H8)?

4. Al Gore: Clean Coal is a Lie

5. Agnes Binagwaho on Brain Drain

When I look at the analytics graphs for these posts, I am struck once again by the ways in which the Web captures ephemeral posts and makes them permanent.

The Plumpy'Nut post received the greatest number of unique page views. In fact, even my posts from 2007 on the controversy surrounding the patent for this nutritional supplement, which helps to save the lives of starving kids, still get a lot of hits. Intriguingly, views of the the post on the demand for Plumpy'nut peaked in July, two months after the post first appeared.

I'm glad to see "At Work with Malawi's Nurses" continues to be popular since it describes the focus of my Nieman Fellowship field project and has occupied a lot of my psychic energy over the past year. It's still chugging along at 58% of its peak back in March.

"Who are the Health Eight (or H8)?" about eight big players in the global health field continues to amaze me. It has had two peaks since it first appeared in April (the second, taller than the first, coincided with the July meeting of the G8 on health in Tokyo) and is currently on its third big upward slope, which seems likely to beat the other two.

My very simple reporting of Al Gore's speech at the Clinton Global Initiative in September, in which he called the concept of "clean coal" a lie, got attention from both the left and right zones of the blogosphere. It is on a second surge, possibly related to the coal ash spill in Tennessee earlier this month.

And the Agnes Binagwaho post, in which she speaks movingly of her own temptation to quit practicing medicine in Rwanda, has the most intriguing web analytics profile--a couple of peaks and valleys that also grow in popularity and that I think mirror the different speeches she has given on university campuses in the U.S.

ProPublica and Conflicts-of-Interest

Hmmm. In a lengthy piece that was otherwise mostly about Herb and Marion Sandler, the New York Times reported last week that Paul Steiger, the editor-in-chief of ProPublica, contacted Lorne Michaels at NBC to protest an utterly tasteless, wickedly funny and potentially libelous skit on Saturday Night Light. The skit depicted the Sandlers, who are the major funders of ProPublica, as corrupt peddlers of predatory mortgages and "people who should be shot."

Okay, so SNL clearly went too far with the "people who should be shot" bit. But the New York Times piece by Michael Moss and Geraldine Fabrikant does make you wonder if maybe the Sandlers should go to jail.

At any rate, NBC pulled the full video from its site and substituted a redacted version that leaves out the Sandler segment entirely--not just the offensive "should be shot" title--but the whole thing. The conservative blogosphere had a field day with this when the flap first occurred in October. But Steiger's role, as far as I can tell, did not come out until last week.

And that's the part that interests me the most at the moment. I'm also teaching a class next May and June on journalistic judgment, although it's about science, health and environment reporting.

Every form of journalism has to deal with conflicts of interest--no matter where the money comes from to pay for it. There is nothing about being a nonprofit organization that earns you a free pass.

This was very clear to me last spring while I was researching and developing a business plan for launching a global health news service. And yet, I was surprised at how much pushback I got on this issue.

This is not rocket science. I am sure that ProPublica has a conflict-of-interest policy for its individual news staff. They should also come up with a policy for its coverage and comments about the Sandlers. Then, they should post their conflict of interest policies on their web site (that section on "privacy policy and other terms" looks about right) and move on.

Ditto for news organizations that take Gates Foundation money to cover global health.

Oh yeah, and as more advocacy groups engage in journalism, they are going to have to come up with their own policies on conflicts of interest.

As for my own potential conflicts: I am a freelancer and former TIME Magazine writer who is passionate about global health and would like to be paid for what she writes. (Believe me, AdSense is not the way to make money in this business.)

Although advertising paid for my salary at TIME, my contacts with the business side were severely limited. In addition, I do not directly own any pharmaceutical or biotech stock. I do not take consulting fees from same. My Nieman Fellowship was paid for by the Gates Foundation but they had no say in my Malawi project.

Writing it down like that is a good reminder.

Video: Mapping NYC's Rats

Back in November when I saw that New York City had turned to computerized mapping software in its renewed fight against rodents, I knew I wasn't going to be satisfied with just a quick blog post. I had to learn more.

After 19 hours of work, including a wonderful but very cold expedition to the Bronx to see Bobby Corrigan and Mike Mills at work, I produced a written piece on rat mapping for Time.com and did the voiceover for the video, which was shot and edited by Ed Robbins.

It's kind of fun to compare the two projects. Text is great for information--and there's plenty of it in my text piece. Audio is ideal for emotion and I recorded several versions of the voiceover--some that sounded a lot more menacing than the one the editors ultimately used. And the video did a much better job of giving you a sense of Bobby's and Mike's personalities than my written piece did.

The written piece was picked up by CNN earlier this month and was one of the most popular pieces on Time.com for a while.

But enough with the media commentary: more importantly, the rat map has helped drive the number of rat problems in the Bronx down 40% in the past year.

Below is a screengrab from NYC's rat map of the abandoned house (upper left corner) where Bobby and Mike introduced Ed and me to their work. (You may need to click on the photo to see the detail.) The official rat map interface is a bit clunky but it yields an utterly fascinating view of New York City.

AIDS Denialists at Change.org

Looks like the AIDS denialists have made a run at change.org--which, I hasten to add, is not affiliated with change.gov, the Obama transition team website. Questioning whether HIV is the cause of AIDS is now the second most popular item in the global health category of change.org.

It's not enough that AIDS denialists have killed at least 330,000 people in South Africa alone. It makes my blood boil to think their juvenile antics, like flooding the simplistic popularity contests at change.org, will keep even a single person with HIV from getting the treatment that she or he needs.

Some valiant commenters have taken up the fight and taken on the denialists at change.org. The guy who originally posted the idea is a total lurker. As of this morning his profile shows he supports no non-profits, has taken no actions, raised no money or recruited anyone to any cause.

Memo to change.org folks: you have been punked.

Wanted: A Brief History of Ideas

Journalists are often told to skip the history when writing the news. Contemporary context is okay. Extended history is out. In rethinking that advice, I offer up Tina Rosenberg’s masterful article on poverty in the Sunday Magazine of the New York Times.

In a few paragraphs, Rosenberg covers nearly half a century of thinking about “the culture of poverty”—at least as far as U.S. intellectuals have described it.

Summary and synthesis, the history of ideas.

That’s increasingly what I am looking for—whether in old media or on the web. And what I find missing in so many discussions about global health.

From Rosenberg’s NYT article:

FORTY-NINE YEARS AGO, the anthropologist Oscar Lewis published a book called “Five Families: Mexican Case Studies in the Culture of Poverty,” detailing a single day in these families’ lives. One family, headed by Jesús Sánchez, a food buyer for a restaurant, continued to tell its story in a second Lewis book, the widely read “Children of Sánchez.” Lewis singled out elements of a culture that, he argued, keep those socialized in it mired in poverty: machismo, authoritarianism, marginalization from organized civic life, high rates of abandonment of illegitimate children, alcoholism, disdain for education, fatalism, passivity, inability to defer gratification and a time orientation fixed firmly on the present.

We still call this the culture of poverty today. But the idea has taken on a life far beyond the world of Mexican peasants. And although the concept originated with Lewis, it has come to mean almost the opposite of what Lewis intended.

Lewis was a man of the left. He saw the culture of poverty as a defense mechanism adapted by the poor in response to capitalist inequality. For a while, the culture of poverty remained a leftist idea: Michael Harrington used it throughout his hugely influential 1962 book, “The Other America,” which laid the foundation for President Johnson’s War on Poverty. But Lewis soon lost control of the concept. With the publication of Daniel Patrick Moynihan’s 1965 report “The Negro Family,” the “culture of poverty” became a shorthand for black ghetto culture, a defect of the poor. Then Edward Banfield, a conservative political scientist, introduced the notion that the culture of poverty was immutable; his 1970 book, “The Unheavenly City,” attacked the key assumption of the War on Poverty — the idea that government can help. Banfield argued that poverty was a product of the poor’s lack of future-orientation, and that nothing government could feasibly do would change that orientation or stop parents from transmitting it to their children.

Banfield’s book is widely seen as retrograde today, but he still seems to own the culture of poverty. Lewis had used the phrase to describe habits acquired in response to structural factors — the standard left-wing argument that people are poor because of low wages, discrimination and bad schools. But the phrase has essentially become shorthand for the right-wing argument that poverty stems from the limitations of the poor and is largely impervious to outside intervention.

Persistent poverty has retreated from the political debate in the United States. But outside the headlines there has been a gentle evolution in thinking about the causes and cures for poverty, one that moves away from blaming capitalism and blaming the poor alike. Today, the most interesting development in that evolution — one with implications for fighting poverty around the world, including in the United States — is coming once again from Mexico, this time from the grandchildren of the children of Sánchez.

Links: Flu, Abortion, Google Data and TB

Seasonal flu. Health experts announce that this year nearly all H1N1 viruses are resistant to oseltamivir (sold as Tamiflu) and responsive to adamantane, amantadine and rimantadine. The opposite is true for H3N2 viruses. (Toronto Sun)

Abortion. Blogger roundup about abortion and women's rights from Brazil (Global Voices Online)

Science Commons. Google shutters its science data service before it is even launched (Wired)

TB. How evolution and human migration make controlling drug-resistant tuberculosis even harder than you think (PLoS Biology)

Jailed Iranian AIDS Docs

Looking ahead to Monday.

The folks at Physicians for Human Rights expect the U.S. State Department to release a statement on the 6-month anniversary of the detention of two AIDS doctors in Iran.

Kamiar and Arash Alaei are internationally known for their work with AIDS and with heroin addicts. Iranian authorities accuse the brothers of trying to promote a "velvet revolution" under the guise of fighting AIDS. (Sounds a lot like the Haleh Esfandiari case to me.)

A quick Google News search shows the Alaeis' detention has so far garnered more mainstream press interest in Europe than the U.S., especially in French-language press.

I learned about the story in an e-mail from Physicians for Human Rights. Read more about their campaign to free the brothers here. (Note to PHR, you need to update the background page on the website. Kamiar Alaei has obviously not returned to his doctoral program at the SUNY Albany School of Public Health.)

The BBC profiled Kamiar and Arash Alaei for their AIDS work back in 2004 as did the Washington Post in 2006.

If you know about this story, please add to the comments below. I will give the comments that provide the most context a full-on post of their own.

Update: the State Department released its statement on the Alaei brothers on Tuesday, Dec. 23, 2008. It reads, in part:

The United States is also deeply concerned by the continued detention of internationally known Iranian HIV/AIDS physicians Dr. Arash Alaei and Dr. Kamiar Alaei. December 22 marked six months since the physicians were arbitrarily arrested by Iranian authorities and detained in Tehran’s Evin Prison. As a party to the International Covenant on Civil and Political Rights, Iran has the obligation to afford due process rights to anyone detained. The two have been active in various international exchange programs and academic research, helping to involve Iranians in the international academic and scientific community.

In November 2006, because of their work on HIV/AIDS, the Alaei brothers were participants in the first professional exchange program for Iranians in almost three decades, sponsored by the U.S. Department of State’s Bureau of Educational and Cultural Affairs. The program, which focused on public health, led to collaboration between American and Iranian medical professionals that could benefit the global fight against HIV-AIDS. Similar programs have brought citizens from over 165 countries to the United States.

The Iranian people have consistently expressed their desire to be connected to the global community. The actions of the Iranian Government against the Alaei brothers, Ms. Ebadi, and other human rights activists only serve to isolate further the Iranian people. With our friends and allies in the region, we stand by the brave people of Iran, who are trying peacefully to exercise their universal human rights, and call upon the Government of Iran to abide by its international obligations.

Twitter and Global Health

I finally gave in and created a Twitter account back on November 4 so I could participate in the #votereport project. It reminded me somewhat of the way mobile phone or SMS texting has shaped elections in Africa, starting with the 2000 election in Ghana and continuing on to the more recent 2008 election in Zimbabwe. It also got me thinking about how such democracy-movement techniques could be adapted to global health. Perhaps to introduce some much-needed transparency in pharmaceutical supply chains?

Votereport was a volunteer-led project that called on U.S. voters to characterize their election experience by providing three major pieces of information: where they voted, how long they waited to vote and whether the experience was a good one or a bad one. If yours was a bad experience, then you were supposed to give a brief description why, e.g. mismatch of your name compared to driver’s license records caused an official to doubt your right to vote.

From a technical point of view, we’re talking about structured-data.

I messed up my first attempt at tweeting my own vote but fortunately someone named ZekeSaysSo showed me how to do it: “#votereport. #10019 #good #wait:40 at 6 AM. longest lines I have ever seen at this polling place at this hour.”

Each specific piece of information was preceded by a # sign or hashtag, also known as a pound sign, to make the information more easily sortable by computer.

People like Adrian Holovaty have convinced a lot of us reporters that one major path to a future for journalism lies through structured data. As Holovaty defined it in 2006, structured data is “the type of information that can be sliced-and-diced, in an automated fashion, by computers.”

Holovaty’s breakthrough example in 2005: using the structured data from Chicago crime statistics mashed up with Google maps to automatically generate geographical pictures of a neighborhood’s character. You can see the latest iteration of his efforts at Everyblock.com

The new wrinkle about Votereport, the Ghanian and Zimabwean elections is that “we the people” provided the structured data—in real time with tangible results. Mobile texting plus radio coverage stopped voting irregularities in Ghana in 2000 and prevented Robert Mugabe from being able to fudge electoral results in Zimbabwe earlier this year—although it didn’t stop him from hanging on to power.

Nothing quite so impressive in the U.S. but Votereport did help a number of individuals cast regular ballots instead of provisional ballots after minor misspellings of their name threatened their franchise rights. Because anyone who tweeted #bad and provided information as to why they couldn’t vote was automatically put into contact with an election protection lawyer. In many cases, simple misunderstandings were resolved before the voting booths closed.

See also Ethan Zuckerman’s thoughtful look at the pros and cons of twittering vs. texting elections.

Seems like you could adapt this type of technology to other uses. I’m thinking specifically about the government’s drug-supply chain in Malawi.

Many, many people I talked to complained about how they can’t get the drugs they need for hospitals and clinics from the Malawi government’s Central Medical Stores. Even the taxi drivers in Lilongwe know that a lot of the pharmaceuticals get diverted from the public sector to the private sector—despite periodic purges of the employees involved.

What if every hospital administrator, clinical officer and nurse used their mobile phone to text every encounter they had with Malawi’s CMS, giving information about the number and kind of drugs that were missing? And you compared that to the number and kind of drugs they started off with—many made available through international agreements?

How long would it take before CMS employees retaliated? Could you get enough people to participate so that no one individual would be targeted for retribution?

Just wondering. What do you think?

See also this Slideshare presentation on Twitter for Health by PF Anderson at the University of Michigan.

Can There Be Too Much Training?

There are many moments from my three-month Malawi trip that I just had to store away for later reflection. I recognized a ring of truth even if I did not quite understand what it meant or how it fit into the larger picture. What a number of people said to me about the role of training—which theoretically seems like a good thing—was just one of these moments that set my head spinning.

A number of managers I interviewed griped that excessive training sessions were distorting the health care system in Malawi. Too many nurses in a country with precious few nurses in the first place were out of their clinic or hospital for various two-week training sessions, often every other month. Several health care workers—particularly in government hospitals—said they depended on the extra pay they got from those training sessions. A couple of Malawians I met who did trainings admitted they could not get anyone to come unless they offered financial incentives.

Now I learn these were not just a few isolated cases. Training and sustainability have turned into perverse incentives in numerous HIV programs in Malawi, according to a new study by Ann Swidler (UC Berkeley) and Susan Cotts Watkins (UPenn and UCLA). I am trying to get a hold of the full paper but this excerpt, provided by Bill Savedoff at the Center for Global Development, is electrifying:

Swidler and Watkins follow the logic of the “sustainability” mantra [Savedoff writes] to show how incentives at every level – from the international donors to the national elites, interstitial elites and local population – make funding for training (and training of trainers) the dysfunctional outcome of an otherwise well-meaning effort. The donors can claim they are “teaching the population to fish,” the national elites get income and status from managing and negotiating the programs, the interstitial elites (usually young high-school-educated volunteers) get contacts and opportunities to rise socially and economically, and the local population gets .. well, relatively little.

[snip]

Swidler and Watkins make the case for what is really needed quite clearly in their final remarks:

"It is hard to say precisely what constructive recommendations follow from the perspective we have offered here, but we do have several suggestions. First, the ideal of sustainability is a convenient self-delusion for funders and they would do much better if they could systematically and rigorously determine what projects are effective and then sustain them by paying local workers to actually do good—provide health care, sell discounted seeds and fertilizers, treat STIs, provide ARVs, supply children with books and school uniforms, or care for the ill and elderly (Kremer & Miguel, 2007).

Second, since few of the approaches to AIDS prevention currently in vogue have shown any measurable effect (Potts et al, 2008), we encourage funding that responds to Malawians’ desire to take care of the vulnerable in their communities, provide for their children’s futures, and build economic security, independent of the issue of HIV and AIDS. Indeed, reading the proposals that Malawian villagers submitted in their usually vain attempts to gain access to AIDS funding convinces us that villagers do know what they want, but little of it is training in how to prevent, mitigate, or treat AIDS. The first two they already know how to do as well as the experts who try to advise them (Watkins, 2004), and treating AIDS has to be done through the health-care system.

"Finally, we suggest that donors consider the “hidden curriculum” their procedures teach. Requirements for elaborate proposals, bank accounts, and monitoring and evaluation might better be replaced by simple procedures that would funnel more resources to villagers and less to monitors. Such resources would create continuing projects that both villagers and employees (perhaps the brighter, more successful of the villagers’ children) might rely upon. Rather than projecting a social imaginary that they find morally gratifying, donors and NGOs might provide opportunities that could sustain the realistic aspirations of those they claim to help."

Hat-tips to Alanna Shaikh and Bill Savedoff for the study.

Links: Varmus, Rape, Methadone

A few worthwhile links on U.S. policy, rape, to start off the workweek.

Harold Varmus speaks on the U.S. commitment to global health on on Tuesday, Dec. 16, 2008 at 11:30 AM Eastern time (U.S.). Videocast will be available at videocast.nih.gov (NIH)

Update: Read the report on global health priorities from the Institute of Medicine on which Varmus bases his recommendations.

Journalist Pushpa Jamieson reports that even asking general questions about rape in a Malawi police station is stigmatizing. (The Chronicle)

Methadone project in Ukraine faces tough sell with public. (Global Voices Online)